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Choi Y, Lee KT. Use of Free Internal Mammary Artery Perforator Flap Harvested With Minimally Invasive Approach for Facial Reconstruction: Report of Two Cases. Microsurgery 2024; 44:e31233. [PMID: 39225063 DOI: 10.1002/micr.31233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 07/02/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
The internal mammary artery perforator (IMAP) flap has been widely used for chest wall and neck reconstruction. The color of its skin paddle closely resembles that of facial skin, making it attractive for facial reconstruction. However, there has been insufficient investigations reporting the use of free IMAP flap. Furthermore, even in such studies, somewhat invasive procedures, including rib cartilage resection, were employed to ensure sufficient pedicle length, potentially increasing donor morbidity. Our report presents two cases of successful facial defect reconstruction using a free IMAP flap harvested with minimal donor site damage, showing its feasibility. In the first case, a 48-year-old male underwent wide excision for a malignant melanoma on his right cheek, resulting in a 4 × 4.5 cm full-thickness defect. A free IMAP flap with a 2.5 cm pedicle, was harvested without rib cartilage resection, preserving IMA main trunk, and transferred with anastomosed to the angular vessels within the defect. The second patient presented with a 4.5 × 3.5 cm basal cell carcinoma on the left cheek, necessitating wide excision and leaving a 6 × 5 cm defect. A free IMAP flap was harvested with the same approach and successfully reconstructed the defect with connected to the superficial temporal vessels using vascular bridge. Both patients were discharged complication-free, with no recurrence during 24 and 15 months of follow-up, respectively. They were highly satisfied with the final skin color and texture outcomes. Harvesting a free IMAP flap while minimizing donor morbidity may offer an attractive option for facial reconstruction.
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Affiliation(s)
- Yun Choi
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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2
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Gorji S, Wessel K, Dermietzel A, Aitzetmueller M, Wendenburg I, Varnava C, Klietz ML, Wiebringhaus P, Hirsch T, Kueckelhaus M. Fully Telemetric Robotic Microsurgery: Clinical Experience With 23 Cases. Microsurgery 2024; 44:e31227. [PMID: 39207211 DOI: 10.1002/micr.31227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 04/16/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Recently, there is an ongoing trend in plastic surgery with robotic-assisted microsurgery and supermicrosurgery devices being developed. Combining a telemetrically controlled robotic microscope with an also telemetrically controlled microsurgery robot unlocks synergistic effects with complete disconnection of the operating surgeon from the operating field. Here, we report the first clinical free flap reconstructions using this setup. METHODS Twenty-three surgeries were performed with the combined remote approach using the Symani Surgical System and the RoboticScope in open microsurgery procedures. Anastomosis time and ischemia time were recorded. The surgical performance for anastomoses was assessed using the modified Structured Assessment of Microsurgical Skills (SAMS) score. Subjective satisfaction was evaluated by the surgeons in comparison with conventional microsurgery. To evaluate the learning curve, the senior authors first four (first group) and last four (last group) procedures were compared. RESULTS Overall, flap survival was 95.7%. The average arterial anastomosis time was 36.7 ± 10.9 min. Total time of surgery was 277.7 ± 63.8 min, and ischemia time was 100.6 ± 24.9 min. Most SAMS score parameters were significantly higher in the last group of surgical procedures compared with the first operations. Subjective satisfaction was equal or better with the combined robotic-assisted approach in most categories. CONCLUSIONS Our data demonstrates safety and feasibility of the use of a combined remote approach. Robotic systems for microsurgical procedures may hold promising potential for improvement of surgical quality and open up new frontiers in microsurgery.
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Affiliation(s)
- Shaghayegh Gorji
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
| | - Kai Wessel
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
| | - Alexander Dermietzel
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Matthias Aitzetmueller
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Isa Wendenburg
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
| | - Charalampos Varnava
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Marie-Luise Klietz
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Philipp Wiebringhaus
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Tobias Hirsch
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Maximilian Kueckelhaus
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
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3
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Vourvachis M, Goodarzi MR, Scaglioni MF, Tartanus J, Jones A, Cheng HT, Abdelrahman M. Utilization of the internal mammary perforators as the recipient vessels for microsurgical breast reconstruction: A systematic review and meta-analysis of the literature. Microsurgery 2024; 44:e31105. [PMID: 37675648 DOI: 10.1002/micr.31105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 07/05/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The selection of reliable recipient vessels is essential for successful free tissue transfer. The use of internal mammary intercostal perforators (IMAPs), instead of the internal mammary vessels as the recipient vessels, has been described in breast reconstruction. Debates exist regarding the reliability of these perforators as recipient vessels because of their variability in location and caliber. The aim of this paper was to conduct a systematic literature review and meta-analysis to determine the reliability of the IMAPs as recipient vessels. METHODS A systematic literature review was performed on the "PubMed," "Medline," "Ovid," and "Cochrane library" databases for articles published from January 1990 to March 2021. Exclusion criteria were non-English studies, reports with case number less than 5, cadaveric or animal studies, and studies with incomplete postoperative outcomes. The reliability of using IMAPs for breast reconstruction was determined by assessing the reported rates of partial or complete flap failure and other complications (fat necrosis, skin necrosis, and requirement for revision surgery). RESULTS Three hundred and sixteen cases in 13 studies were included for further analysis with more than 85% of the IMAPs suitable for anastomosis being located in the second and third intercostal spaces. Partial or total flap failure was reported in three of 316 patients (0.95%). The rate of other complications such as fat necrosis, skin necrosis, and requirement for revision surgery were all less than 5%. CONCLUSION With deliberate preoperative planning, delicate perioperative manipulation, and meticulous microvascular anastomosis, the internal mammary perforators can be used as reliable recipient vessels in microvascular breast reconstruction.
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Affiliation(s)
- Michail Vourvachis
- Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Mohammad R Goodarzi
- Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Mario F Scaglioni
- Department of Hand and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Justyna Tartanus
- Department of General Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Alex Jones
- Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Hsu-Tang Cheng
- Department of Plastic and Reconstructive Surgery, Asia University Hospital, Taichung City, Taiwan
| | - Mohamed Abdelrahman
- Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough, UK
- Department of Surgery, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
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4
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Friebel TR, Shanmugakrishnan RR, Zberea D, Morgan M, Hussain A, Ramakrishnan V. Internal mammary perforator vessels as recipient for microvascular breast reconstruction: Technique and outcomes in 161 flaps. J Plast Reconstr Aesthet Surg 2023; 85:454-462. [PMID: 37586312 DOI: 10.1016/j.bjps.2023.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/14/2023] [Accepted: 07/16/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The use of internal mammary perforator (IMP) vessels as recipients for free flap breast reconstruction was first described in 1999. Despite numerous advantages over the internal mammary (IM) and thoracodorsal recipient vessels, their widespread use remains mired in concern. This paper describes our method of IMP vessel preparation and outcomes with regard to safety and reliability. METHODS To support the reliability of the IMP vessel preparation, a retrospective study on prospectively collected data of all free flap breast reconstruction patients between 1 July 2016 and 31 July 2019 was performed. Data were collected on patient demographics, type of reconstruction operative details and complications. RESULTS Out of the 450 flaps performed, the IMP vessels were used in 36% of the cases. Of these cases, 18% had received neo-adjuvant chemotherapy and 15% had a history of radiotherapy to the chest wall. In total, 161 flaps were performed to reconstruct 138 breasts (115 single and 23 stacked flaps). Three patients required a return to theatre, with one needing recipient vessel revision from the IMP to the IM vessels due to calibre mismatch. No mastectomy skin flap necrosis, free flap loss or significant fat necrosis were encountered. CONCLUSION This article describes an IM vessel preparation method that results in predictable outcomes in both single and stacked flap reconstructions with a low complication rate. Due to their reliability and versatility, we consider the IMP vessels a valuable attribute to the recipient vessel arsenal of any breast reconstruction microsurgeon.
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Affiliation(s)
- Thessa R Friebel
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom.
| | - R Raja Shanmugakrishnan
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
| | - Diana Zberea
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
| | - Mary Morgan
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
| | - Amer Hussain
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
| | - Venkat Ramakrishnan
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
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5
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Fernandez-Diaz OF, Christopoulos G, Griffiths M. A Systematic Review and Meta-analysis of Clinical Outcomes in Autologous Breast Reconstruction Using Internal Mammary Artery Perforators as Recipient Vessels. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4969. [PMID: 37207242 PMCID: PMC10191480 DOI: 10.1097/gox.0000000000004969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/13/2023] [Indexed: 05/21/2023]
Abstract
Recipient vessel selection is vital for successful autologous free-flap breast reconstruction. Internal mammary artery perforators have gained interest as a recipient vessel option. However, previous studies on their microsurgical safety and efficacy are limited and inconsistent. Thus, we conducted a systematic review and meta-analysis to assess the safety and effectiveness of using internal mammary artery perforators as recipient vessels in breast reconstruction. Methods The protocol has been previously published in PROSPERO (CRD42020190020). The PubMed, Scopus, Web of Science, and PROSPERO databases were searched. Two independent reviewers evaluated the articles for inclusion in the study. Study quality was assessed using the Newcastle-Ottawa Scale and the MINORS instrument (Methodological Index for Non-Randomized Studies). Results Of the 361 articles screened, 13 studies were included (313 patients with 318 flaps; 223 unilateral, 31 bilateral, mean average age 51.2 and mean BMI 27.8 ± 1.9). The mean overall success rate was 99.8%, the pooled surgical success rate was 100% [95% confidence interval (CI): 97%-100%], and the overall rate of complications was 11% (95% CI: 7%-18%). The most common complication was vascular-related to microanastomoses, with an incidence of 5% (95% CI: 2%-10%). The fat necrosis rate was 3% (95% CI: 2%-6%). Conclusions This study verified that internal mammary artery perforator vessels are reliable in breast reconstruction, with a high success rate and a relatively low complication rate. Moreover, in selected microsurgical breast reconstruction patients, internal mammary artery perforators may be the primary recipient vessel choice over the internal mammary artery or thoracodorsal vessels.
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Affiliation(s)
- Oscar F. Fernandez-Diaz
- From the St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, UK
- Group for Academic Plastic Surgery, Blizard Institute, Queen Mary University of London, London, UK
| | - Georgios Christopoulos
- Group for Academic Plastic Surgery, Blizard Institute, Queen Mary University of London, London, UK
- Department of Plastic Surgery, Queen Victoria Hospital, East Grinstead, West Sussex, UK
| | - Matthew Griffiths
- From the St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, UK
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Technical and anatomic considerations of skin flap elevation in bilateral axillo-breast insufflation robotic-assisted neck dissection. J Robot Surg 2023:10.1007/s11701-023-01536-8. [PMID: 36637736 DOI: 10.1007/s11701-023-01536-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/08/2023] [Indexed: 01/14/2023]
Abstract
We have divided the chest and neck flap elevation for neck dissection into four steps. The flaps are divided into three zones corresponding to the vascular structures, which can be injured in this area. Our modifications outline safe techniques of flap elevation for robotic neck dissection.
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Standardized Skin Flap Warming Effectively Improves Flap Survival without Obstructing Temperature Monitoring after DIEP. PLASTIC AND RECONSTRUCTIVE SURGERY - GLOBAL OPEN 2022; 10:e4153. [PMID: 35242493 PMCID: PMC8884534 DOI: 10.1097/gox.0000000000004153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/04/2022] [Indexed: 11/26/2022]
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8
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Diametric Comparison between the Thoracodorsal Vessel and Deep Inferior Epigastric Vessel in Breast Reconstruction. BIOMED RESEARCH INTERNATIONAL 2020; 2020:6352939. [PMID: 32724804 PMCID: PMC7381952 DOI: 10.1155/2020/6352939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/25/2020] [Accepted: 07/07/2020] [Indexed: 11/17/2022]
Abstract
Background In microvascular anastomosis, size discrepancy is common and can increase thrombotic complications. If size differences can be predicted, then vessels of the appropriate size can be selected. This study documented the difference in diameter between the thoracodorsal (TD) vessel and deep inferior epigastric perforator (DIEP) pedicle in each patient who underwent breast reconstruction using free tissue transfer. Patients and Methods. This retrospective study included 32 anastomoses (27 breasts including five cases of supercharged anastomosis) of breast reconstruction with the free DIEP flap and TD recipient between August 2018 and June 2019. In the microscopic view, the caliber of the TD vessel, the largest branch to the serratus anterior muscle, the descending branch, the largest and the second largest branches to the latissimus dorsi muscle, and the DIEP pedicle were measured. Results The diameter of the deep inferior epigastric artery was similar to that of the descending branch, and their anastomosing rate was 56.3%. The diameter of the deep inferior epigastric vein was similar to the branch to the serratus anterior muscle and the descending branch, and their anastomosing rates were 29.3% and 29.3%, respectively. All flaps were survived; however, in one case, a reoperation was needed to remove the hematoma, in which case fat necrosis occurred as the only complication. Conclusion TD branches of similar size to the DIEP pedicle were prioritized in anastomosis. The descending branch and the branch to the serratus anterior muscle are expected to be good candidates as recipients in breast reconstruction with DIEP free flap. Moreover, supercharged anastomosis of DIEP pedicles can be achieved within TD branches.
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Zhang Q, Xiao Q, Guo R, Xiu B, Li L, Chi W, Gu Y, Wu J. Applications of rib sparing technique in internal mammary vessels exposure of abdominal free flap breast reconstructions: a 12-year single-center experience of 215 cases. Gland Surg 2019; 8:477-485. [PMID: 31741878 DOI: 10.21037/gs.2019.08.08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Internal mammary vessels (IMVs) are widely used recipient vessels in abdominal free flap breast reconstructions. Rib sparing technique is an alternative method with less damage in IMVs exposure. This study aims to investigate the factors influencing the selection of IMVs, as well as analyze the applicability and related factors of rib sparing technique in abdominal breast reconstruction. Methods Medical records of 215 patients who underwent abdominal free flap reconstruction from November 2006 to December 2017 in Fudan University Shanghai Cancer Center (FUSCC) were analyzed. Intercostal space (ICS) was measured from preoperative chest computed tomography scan. Factors influencing the choice of recipient vessels and rib sparing were analyzed. Surgery time, hospitalization and complications were assessed. Results Among all 218 flaps, 172 flaps used IMVs as the recipient vessels while 46 used other vessels. patients with immediate reconstruction (P=0.005) and axillary lymph nodes dissection (ALND) (P<0.001) were less likely to use IMVs. Patients' body mass index (BMI) and radiotherapy history showed no statistically significant differences between the two groups (P=0.338 and 0.811). In IMVs group, 62% cases used rib sparing technique. Compared with rib resection group, patients with rib sparing were taller (P=0.047) and with a wider ICS (2.65±0.54 vs. 2.25±0.38 cm, P<0.001). Rib sparing group had a shorter surgery and postoperative hospitalization time, as well as a lower complication rate, but the differences were not statistically significant (P=0.120, 0.450 and 0.612). Conclusions IMVs were used more frequently as the recipient vessels in abdominal free flap breast reconstructions, especially when axillary operation was not performed at the same time. Rib sparing technique had the potential to decrease surgery time, hospitalization days and complications rate. It could be applied in most of the patients with IMVs exposure, particularly in taller patients and patients with a wider ICS. Preoperative chest computed tomography scan can be used to assess the ICS width to provide operational suggestions.
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Affiliation(s)
- Qi Zhang
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qin Xiao
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Rong Guo
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Bingqiu Xiu
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Lun Li
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weiru Chi
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yajia Gu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Jiong Wu
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Collaborative Innovation Center for Cancer Medicine, Shanghai 200032, China
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10
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Shin D, Sung KW, Fan KL, Park TH, Song SY, Roh TS, Lew DH, Lee DW. Expanding the use of internal mammary artery perforators as a recipient vessel in free tissue transfer: An anatomical analysis by computed tomography angiography in breast cancer patients. Microsurgery 2019; 39:509-514. [PMID: 30830973 DOI: 10.1002/micr.30446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 01/25/2019] [Accepted: 02/22/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND The internal mammary artery (IMA) perforator has assumed recent prominence as recipient vessels in free autologous breast reconstruction. However, anatomical understanding is unclear, due to limited cadaver and clinical studies. We evaluated the usability of these vessels by evaluating perforator size, dominance, laterality, interspace location, and relationship with breast volume. METHODS A retrospective review assessed 197 female patients with breast cancer who had undergone computed tomography angiography (CTA) of the chest wall. The average age and body mass index (BMI) of patients was 49.0 ± 6.5 years and 24.2 ± 5 .8 kg/m2 , respectively. The average volume of breasts was 437 ± 190 mL. Our analysis focused on the anatomy of IMA perforator and its relationship to volume and BMI. RESULTS A total of 377 hemi-chest evaluations were performed. Most patients (95.5%) had sizeable perforating artery identified on CTA. Among all sizeable perforators identified, the mean diameter of the most dominant arterial perforator was 1.8 ± 0 .8 mm. The right hemi-chest had significantly larger perforators than the left (1.9 ± 0 .9 mm vs. 1.7 ± 0 .7 mm, p = 0.002). The first intercostal space (ICS) had a slightly greater of perforators than second ICS (34.6% vs. 29.8%, p = 0.172). However, second ICS had a greater number of most dominant perforators compared to first ICS (38.9% vs. 34.7%, p = 0.357). Perforators from first ICS emerge medial to the sternal edge and breast footprint. When dividing groups with 0-1 versus 2-3 reliable perforators, breast volume was significantly higher in the later (422.0 mL vs. 461.2 mL, p = 0.019). CONCLUSION These results are expected to encourage microsurgeons to use the IMA perforator by providing a clear anatomical roadmap.
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Affiliation(s)
- Dongwoo Shin
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Ki Wook Sung
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Tae Hwan Park
- Department of Plastic and Reconstructive Surgery, Bundang CHA Medical Center, Seongnam, Gyeonggi-do, South Korea
| | - Seung Yong Song
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Tai Suk Roh
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Dae Hyun Lew
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Won Lee
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
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11
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Moon KC, Lee JM, Baek SO, Jang SY, Yoon ES, Lee BI, Park SH. Choice of recipient vessels in muscle-sparing transverse rectus abdominis myocutaneous flap breast reconstruction: A comparative study. Arch Plast Surg 2019; 46:140-146. [PMID: 30934178 PMCID: PMC6446025 DOI: 10.5999/aps.2018.00913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/08/2018] [Accepted: 10/30/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Thoracodorsal vessels (TDVs) and internal mammary vessels (IMVs) have both been widely employed as recipient vessels for use in free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps. However, whether TDVs or IMVs are preferable as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap remains controversial. The purpose of this study was to compare the clinical outcomes when TDVs were used as recipient vessels to those obtained when IMVs were used as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap. METHODS A retrospective matched-cohort study was performed. We retrospectively reviewed data collected from patients who underwent a free MS-TRAM flap for autologous breast reconstructions after mastectomy between March 2003 and June 2013. After a one-to-one matching using age, 100 autologous breast reconstructions were selected in this study. Of the 100 breast reconstructions, 50 flaps were anastomosed to TDVs and 50 to IMVs. Patient demographics and clinical outcomes including operation time, length of hospital stay, postoperative complications, and aesthetic score were compared between the two groups. RESULTS No statistically significant differences were found between the two groups in patient demographics and clinical outcomes, including the complication rates and aesthetic scores. There were no major complications such as total or partial flap loss in either group. CONCLUSIONS The results of our study demonstrate that both TDVs and IMVs were safe and efficient as recipient vessels in terms of the complication rates and aesthetic outcomes.
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Affiliation(s)
- Kyung-Chul Moon
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jae-Min Lee
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Si-Ook Baek
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seo-Yoon Jang
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Eul-Sik Yoon
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Byung-Il Lee
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seung-Ha Park
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
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Kim DH, Kim CW, Lee JW, Kim U, Jung S, Hwang E. Distribution of internal thoracic artery perforators: A clincal anatomy study. Clin Anat 2018; 32:471-475. [PMID: 30421817 DOI: 10.1002/ca.23312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/11/2018] [Accepted: 11/09/2018] [Indexed: 11/09/2022]
Abstract
There are various modifications of the transverse rectus abdominis musculocutaneous flap and deep inferior epigastric perforator flap to reduce the morbidity of the donor site or to augment the vascularity of the flap. For microanastomosis of multiple pedicles, multiple recipient vessels or an intervening vein graft should be provided. In addition, alternative perforator-based flaps used in breast reconstruction have small caliber pedicles. Therefore, small recipient vessels such as internal thoracic artery perforators are more suitable for appropriate microanastomosis. Therefore, it is important to acquaint the distribution and anatomical characteristics of internal thoracic artery perforators. We researched the perforators running in the intercostal spaces under the pectoralis major muscle to provide an overview of the anatomical distribution and characteristics of the perforators in patients who underwent immediate subpectoral implant-based breast reconstructions. In our study, the major perforators (diameter > 1.5 mm) were easily found 2-7 cm medially between the third and fourth intercostal space and were sparse in the lateral area from the midline of the breast (usually 8-9 cm lateral to the midsternal line) and above the third rib. In each side of the breast, the average number of perforators greater than 1.5 mm was 1.6, and the average number of perforators between 1 mm and 1.5 mm in diameter was 3.2. Our results provide information about perforators in the anterior chest wall related to the breast area. Clin. Anat. 32:471-475, 2019. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Dae Hee Kim
- Department of Biomedical Engineering, College of Medicine, Seoul National University, Seoul, South Korea
| | - Chan Woo Kim
- Department of Plastic and Reconstructive Surgery, Bundang CHA Medical Center, School of Medicine, CHA University, Seongnam, South Korea
| | - Jang Won Lee
- Department of Plastic and Reconstructive Surgery, Bundang CHA Medical Center, School of Medicine, CHA University, Seongnam, South Korea
| | | | - Soyeon Jung
- Department of Plastic and Reconstructive Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Euna Hwang
- Department of Plastic and Reconstructive Surgery, Bundang CHA Medical Center, School of Medicine, CHA University, Seongnam, South Korea
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